Anesthesia Coding Alert

Start documenting before the procedure to help win the bottom line battle.

Selecting the correct anesthesia code for a surgical procedure can be tricky enough some days when you're coding for a well-defined surgery. Start tackling procedures that don't align with an anesthesia code, however, and you're dealing with one of the biggest coding challenges: obtaining appropriate payment for unlisted procedures.

Roadblock: The medical policies for many payers include disclaimers that every benefit plan defines which services are covered and which are excluded. The next time your physician provides a service that doesn't fall neatly under a CPT code and you resort to "unlisted," keep these tips in mind to bolster your chances at reimbursement.

Connect With a CPT Code

"Find a way to relate the procedure to an existing CPT code as support for reimbursement. Also explain, however, how your physician's procedure differs to show why you didn't choose the existing CPT code", says Heather Corcoran, manager at CGH Billing Services in Louisville, Ky.

Example: The anesthesiologist intubated and sedated a child with severe asthma before the child underwent Forane therapy under anesthesia. CPT does not include an anesthesia code for inhalation therapy, so you'll need to relate the procedure to an existing code. Ask the anesthesia provider whether the value can be compared to a closed chest procedure (00520, Anesthesia for closed chest procedures; [including bronchoscopy] not otherwise specified; base value of 6). "If not, ask what base value is appropriate and report the procedure with that number of units and 01999 (Unlisted anesthesia procedure[s])," advises Kelly Dennis, MBA, ACSAN, CANPC, CHCA, CPC, CPC-I, owner of Perfect Office Solutions in Leesburg, Fla.

Plan for Pre-Authorization

Take steps toward payment before the procedure occurs. Try to obtain pre-authorization from the payer in writing, and include any relevant documentation.

Example: You're trying to obtain pre-authorization for a pain management procedure for which you'll submit an unlisted code. Describe the patient's condition and how the pain is impacting her life and health. Include any information related to clinical trials for the procedure conducted by recognized physicians, and a lay-term description of the procedure so anyone reading the letter can understand. Educate the payer on the anticipated cost of care with and without the procedure; let the payer know if how much money could be saved if the procedure is done to reduce the chance of future, more expensive procedures. Finally, include CPT codes with comparable levels of work and risk to help set reimbursement.

Remember: Payers consider claims with unlisted procedure codes on a case-by-case basis, and determine payment based on the documentation you provide. Unfortunately, claims reviewers frequently do not have a high level of medical knowledge, and physicians don't always dictate the most informative notes.

Move Away From Modifiers

Don't append modifiers to unlisted procedure codes, because the unlisted procedure codes do not describe specific procedures.

Purpose: A modifier (such as modifier 23, Unusual anesthesia) indicates that a service or procedure identified by a specific CPT code has been altered by some circumstance, but not changed in its definition. Modifiers can also be used to provide additional information to a payer about a procedure. Unlisted procedure codes don't have a description for the modifiers to change.

CPT Assistant (April 2001) added support to this issue by stating that since unlisted codes do not include descriptor language that specifies the components of a particular service, there is no need to "alter" the meaning of the code.

Final note: Ultimately, you should always adhere to the AMA official coding guidelines unless your contract with a payer stipulates otherwise. If you have had difficulty with a payer processing any unlisted procedure code, then you may address the issue with the payer representative who may, in writing, direct your provider that it is OK to report a CPT code not following the AMA CPT guidelines.